Patient Forms

THE FOLLOWING ITEMS MUST BE COMPLETED AND/OR
RECEIVED IN ORDER TO SCHEDULE YOUR CHILD FOR
DENTAL TREATMENT

First page of Oral Rehab Booking Information. You must indicate your medical insurance, not your dental insurance information.

You must supply a copy of your medical insurance card, front and back, a minimum of one week prior to the appointment. (If not received, you may be responsible for the facility and anesthesia fees.)

If you are other than the natural mother or father and have legal responsibility for the child, we require a copy of the document appointing you legally responsible. This information is necessary because only the legally responsible party can sign the Consent for Anesthesia and Conditions of Admission on the day of surgery.

• Download New Patient Packet

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